• Performs ICD-10-CM diagnostic and current procedural terminology procedural coding to maintain an accurate database and
ensure accurate coding at minimum accuracy rate of 95%.
• Competent in the utilization of an electronic medical record, and
computerized coding/abstracting systems.
• Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any
additional regulatory guidelines and/or coding references to select diagnosis and all significant procedures, indicating the patient’s
acuity, severity of illness and risk of mortality (if applicable) and all charges as documented in the medical record.
• Applies knowledge of ambulatory payment classification reimbursement for procedure coding, current procedural terminology guidelines,
knowledge of local coverage determination's for medical necessity, and appropriate use of modifiers.
• Effectively and professionally communicates with providers to clarify documentation in order to assign accurate diagnoses and procedures for
ambulatory payment classification and for medical necessity.
• Ability to code using either 3M encoder or ICD-9-CM/ICD-10-CM book.
• Performs E/M (Evaluation Management) coding for physician and facility with a minimum accuracy of 95%.
• Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of
changes in codes, coding guidelines and regulations.
• Maintains certified coding credentials in accordance with the certified coding requirements and demonstrates annual compliance.
• Achieves the organization's established expectations with regard to
customer service, teamwork and safety.
• Responds to all questions regarding diagnoses and procedures with the billing office in a timely manner.
• Fulfills all compliance responsibilities related to the position.
• Performs other duties as assigned.
Education, Skills, Experience
Essential: CPC, COC, CCS, or CCS-P certification Required: Specialized training in medical terminology, ICD-10-CM Diagnosis, CPT
procedure and E/M coding. Able to decipher operative reports, medical orders, and various medical records in the appropriate
selection of codes. Experience in acute care coding with outpatient records. Minimum Experience: 2 years demonstrated coding
experience in appropriate application of coding and documentation guidelines Desired: Course work in Anatomy and Physiology.
Education * HS Graduate or Equivalent